Why Aren’t Gay Men On The Pill? Ctd

The New York Times has produced a “Room for Debate” colloquium on Truvada, the daily pill to prevent HIV infection. They lead with the Michael Weinstein, who writes this sentence:

PrEP has failed to protect the majority of men in every clinical trial (study).

He links to an Indian summary of drug trials from 2011. That ignores the data since then:

A key Truvada study found more than 90 percent effectiveness in preventing HIV infection even among those not fully compliant with the one-pill-a-day regimen. Another study showed that “parti­ci­pants could re­duce their risk of HIV by 76 pe­r­cent tak­ing two doses per week, 96 pe­r­cent by tak­ing four doses per week, and 99 pe­r­cent by tak­ing se­ven doses per week.”

That’s a huge majority in all the most recent studies. Then we have Larry Kramer writing the following:

Truvada is a form of chemotherapy, and we have not faced up to the possible side effects that might come.

truvadaChemotherapy? He sounds like someone’s hysterical grandma from a Roz Chast cartoon. It’s one pill a day whose side effects have been documented as minimal for the vast majority and easily monitored for anyone else. You get your bloodwork every three months. The drug has been used in combination for several years and has no resemblance even slightly to chemotherapy in any form. Of course, with any drug, including aspirin, there are side effects. But they pale in comparison to the side-effects of the full anti-HIV cocktail – which is the real life alternative to this simple pill a day.

So where are these people coming from?

If they were deadly serious about reducing HIV infections, why wouldn’t they want every possible means of prevention? Why, in fact, continue to favor an approach that has already demonstrably failed, rather than try a new one that might work? One clue comes from a sentence like this from Weinstein:

What we do know is that this generation didn’t live through the holocaust of the ’80s and ’90s.

As if that’s a bad thing! It doesn’t seem to occur to him that sex without terror is a good thing, in fact, an extraordinarily good thing for a fully realized life. Or that adjusting your behavior when the cost-benefit analysis decisively shifts is a perfectly rational thing to do. The same blindspot is in Larry’s sentence:

There is already a lot of complacency among gay men that makes the lucky uninfected neglect or reject condom use.

Complacency? It doesn’t seem to occur to Larry that it’s not complacency, but rationality at work here. Adjusting your behavior when the cost-benefit analysis decisively shifts is a perfectly rational thing to do. The only people being complacent with HIV are those “mainly” using condoms, hoping for the best when they lapse from time to time, and not taking Truvada. Why would Kramer not support someone attempting to make his own body as immune to HIV as possible – with a safety net as well as protective gear?

What we’re seeing perhaps is the understandable trauma of an older generation cramping the options of a younger one, in a different time, with different – and much less terrible – problems. The obvious drawback is the possibility that fewer condoms means more other STDs. But the check-ups required for continued use of Truvada can be a warning sign for that; and one study has found no probability of such unintended consequences. Maybe they’ll occur and we can adjust. But right now, we have a lethal weapon in the fight to the most lethal STD there is, and we’re unconscionably failing to use it.

The long-running Dish thread on the male pill is here. Update from a reader:

Thanks for continuing to cover Truvada. I’m a 54-year-old gay man, HIV-negative, lived in San Francisco in the early ’80s (and have lived to tell about it). I don’t have unprotected sex (truth be told, I don’t have much sex, period, but that’s another story). But at my last doctor’s visit, I went on Truvada. My doctor was unfamiliar with it (my gay doctor!), but he was happy to prescribe it. He said it seemed “a bit like overkill, but when the alternative is a life-and-death condition, is there such a thing as overkill?” My health insurance covers it, and so far no side effects that I can tell.

My reasons for going on Truvada are mostly emotional (what a spectre of fear relieved!) and political. As part of the political aspect, I’ve begun telling people that I am taking Truvada. The stigma attached to it needs to be removed, and having more people on the drug will enlarge the medical track record as well as, eventually, bringing the price down.

When I told two women friends about it, and the very high prevention rate some tests show, she said, “Why aren’t they putting it in the drinking water?” The other, in response to the idea that if gay men won’t even always wear a condom, how can they be expected to take a pill daily, pointed out that women on birth control seem to handle taking a pill every day.